43

X!. NURS!NC CARE PLANS Nursing Care Plan #1

ASSESSNENT NURS!NC
D!ACNOS!S
RAT!ONALE DES!RED
OUTCONE
NURS!NC
!NTERvENT!ON
]UST!F!CAT!ON EvALUAT!ON
Actual Abnormal Cues:

O Kung minsan hindi ko
na kaya nagpapatali na
lang ako, ! can hear
voices", as verbalized
by the client.
O Attention deficits
O !nability to make
decisions

Risk Related Factors:

History of drug and
alcohol abuse

Strength:

O Compliance to
medication
O Cood family support
O Positive attitudes
towards his situation

Disturbed sensory
perception: auditory
related to biochemical
imbalances for sensory
distortion as evidenced
by hearing unusual
voices

Definition:

Change in the mount or
patterning of incoming
stimuli accompanied by a
diminished, exaggerated,
distorted, or impaired
response to such stimuli.

Source:
(Doenges, 2006)

PRED!SPOS!NC/
PREC!P!TAT!NC FACTOR:
Substance abuse

Passed on the blood brain
barrier

Prolonged
vasoconstriction of
blood vessels in the
brain

Decrease blood circulation in
the brain

Poor oxygenation in the brain

Neurodegeneration of the brain

Dysfunction in the
prefrontal cortex

Release of
excessive dopamine

Excites psychosis

Signs and Symptoms: Auditory
disturbances such as auditory
hallucinations, attention deficits
and inability to make decisions

Disturbed sensory
perception: auditory


Source:
(videbeck, 2004)
(Stuart, 200S)
(Old notes in Psychiatric
Nursing)
After 4 days of nurse
client interaction, the
client will be able to:


O Demonstrate
decreased
hallucinations.




O !nteract appropriately
with others and with
the environment.



O verbalize plans to
deal with
hallucinations, if they
occur.











!ndependent:

O Try to decrease stimuli
or move the client to
another area.



O Engage the client in
conversation or
concrete activity.




O Encourage client to tell
staff members and
student nurse about
hallucinations.


Collaborative:

O Refer to experts in the
field of psychiatry for
advice.


O To decrease the
chances of
misperception.



O To distract client from
responding to
hallucinations.




O To help client to cope
with problems about
hallucinations.






O To assess
causative/contributing
factors and degree of
impairment.


Source:
(Fortinash, 2007)
After 4 days of nurse
client interaction, the
client will be able to:


O COAL NET - client
was able to verbalize
that he does
hallucinate sometime
but not frequent.

O COAL NET - client
was participating
during the activity
and has friends in the
institution.


O COAL NET - client
said that in order to
deal with
hallucination, he tell
others to tie him to
avoid him from
hurting his self and
others.

44

Nursing Care Plan #2
ASSESSNENT NURS!NC
D!ACNOS!S
RAT!ONALE DES!RED
OUTCONE
NURS!NC
!NTERvENT!ON
]UST!F!CAT!ON EvALUAT!ON
Actual Abnormal Cues:

O ! don't want to go
out in this institution
baka may masamang
mangyari sa family ko
dahil sakin." As
verbalized by the
client.
O Expressed concerns
due to change in life
events

Risk Related Factors:

History of drug and
alcohol abuse

Strength:

O Compliance to
medication
O Cood family support
O Positive attitudes
towards his situation

Anxiety related to
threat of danger as
evidenced by expressing
concerns due to changes
in life events, unusual
thoughts about possible
danger he may bring to
his family


Definition:

vague, uneasy feeling of
discomfort or dread
accompanied by an
autonomic response, a
feeling of apprehension
caused by anticipation of
danger. !t is an alerting
signal that warns of
impending danger and
enables the individual to
take measures to deal
with the threat.


Source:
(Doenges, 2006)

PRED!SPOS!NC/
PREC!P!TAT!NC FACTOR:
Negative life experiences

low selfesteem and
emotionally unstable

Emotional Conflict

Signs and Symptoms:
unusual thoughts and
feelings of danger

Anxiety












Source:
(videbeck, 2004)
(Stuart, 200S)
(Old notes in Psychiatric
Nursing)
After 4 days of nurse
client interaction, the
client will be:


O Able to continue
necessary activities
even though anxiety
persists.



O Able to verbalize
needs and negative
feelings appropriately



O Able to avoid
demonstration of
aggressive behavior.





!ndependent:

O Provide positive
reinforcement when
patient is able to
continue ADLs and
other activities
despite of anxiety.

O Encourage patient
verbalize thoughts
and feelings





O Reduces excessive
stimulation by
providing quiet
environment and
limit of caffeine and
other stimulants.

Collaborative:

Administer medication as
prescribed.



O To divert patient's
attention to something
interesting.



O To decrease the
burden felt by the
patient.





O To prevent
unnecessary things to
occur that may harm
him or others.






To reduce anxiety.


Source:
(Fortinash, 2007)
After 4 days of nurse
client interaction, the
client will be able to:


O COAL NET - patient
was able to participate
activities prepared for
them



O COAL NET - patient
was able to verbalize
feelings of danger
when he will be out of
the institution to the
student nurse

O COAL NET - patient
does not harm
anybody and know
what to do when
aggressive behavior
occurs.
4S

Nursing Care Plan #3

ASSESSNENT NURS!NC
D!ACNOS!S
RAT!ONALE DES!RED
OUTCONE
NURS!NC
!NTERvENT!ON
]UST!F!CAT!ON EvALUAT!ON
Risk Cues:

! can hear voices telling
me, ikaw may sala nga
napatay siya and then
nagiging restless na ako,
! try to cut my arms", as
verbalized by the client.

Related Factors:

O History of suicide
attempt
O History of drug and
alcohol abuse.


Strength:

O Cood family support
O Compliance to
medication
O Positive outlook
towards recovery.

Risk for self directed
violence related to
auditory disturbances


Definition:

At risk for behaviors in
which an individual
demonstrates that he or
she can be physically,
emotionally, and/or
sexually harmful to self.















Source:
(Doenges, 2006)


PRED!SPOS!NC/
PREC!P!TAT!NC FACTOR:
Substance abuse

Passed on the blood brain
barrier

Prolonged
vasoconstriction of
blood vessels in the
brain

Decrease blood circulation in
the brain

Poor oxygenation in the brain

Neurodegeneration of the brain

Dysfunction in the
prefrontal cortex

Release of
excessive dopamine

Excites psychosis

Signs and Symptoms: Auditory
disturbances such as auditory
hallucinations

Risk for self directed
violence


Source:
(videbeck, 2004)
(Stuart, 200S)
(Old notes in Psychiatric
Nursing)
After 4 days of nurse
client interaction, client
will be able to:

O Name of the things
he was doing to
prevent him from
hurting himself.


O Participate in care
and meet own needs
in an assertive
manner.


O Express realistic self
evaluation and
increase sense of
selfesteem.
!ndependent:

O Develop therapeutic
nurseclient
relationship.



O Assist client to learn
assertive rather than
manipulative,
nonassertive or
aggressive behavior.

O Cive client as much
control as possible
within constraints of
individual situation.


Collaborative:

O Refer to psychologist or
psychiatrist for
counseling.


O To promote sense of
trust allowing client to
discuss feelings openly.

O To promote behavior
that help client to
engage in positive
social activities with
others.


O To enhance self
esteem, promotes
confidence and ability
to change behavior.





O To evaluate further the
patient's condition.




Source:
(Fortinash, 2007)
After 4 days of nurse
client interaction, client
will be able to:

O COAL NET - client
verbalized ! asked
them to tie me up to
prevent me from
hurting myself".


O COAL NET - client
was attentive during
discussions and
activities such as OT
and exercises

O COAL NET - client
was able to accept his
condition.